Life-threatening: silent chest, poor effort, exhaustion, cyanosis, SpO2 under 92%, agitation or reduced consciousness. Start back-to-back bronchodilators, give oxygen, and call for senior and critical care help.
First actions
- Oxygen to keep SpO2 94 to 98%
- Salbutamol: 10 puffs via spacer (moderate) or nebuliser (severe or life-threatening)
- Add nebulised ipratropium if severe or poor response
- Early oral prednisolone (or IV hydrocortisone if vomiting)
Escalation options (senior led)
- IV magnesium sulphate
- IV salbutamol or aminophylline per protocol
- Reassess continuously; high-dependency or PICU if deteriorating
- Beware a normalising or rising CO2
Moderate
- SpO2 92% or more, able to talk
- PEF 50% or more if measurable
- Salbutamol via spacer
Acute severe
- SpO2 under 92%, too breathless to feed
- HR and RR raised for age
- Nebulised salbutamol and ipratropium
Life-threatening
- Silent chest, cyanosis, poor effort
- Exhaustion or confusion
- Senior and PICU, IV therapy
Paediatric attack
1
1. Bronchodilator
Salbutamol 10 puffs via spacer (moderate) or nebulised (severe or life-threatening), repeated as needed. Add ipratropium if severe.
Salbutamol 10 puffs via spacer (moderate) or nebulised (severe or life-threatening), repeated as needed. Add ipratropium if severe.
↓
2
2. Steroids
Oral prednisolone early, dosed by age (or IV hydrocortisone if not tolerating oral). A 3-day course is usually enough.
Oral prednisolone early, dosed by age (or IV hydrocortisone if not tolerating oral). A 3-day course is usually enough.
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3
3. Escalate
If poor response: IV magnesium, then IV salbutamol or aminophylline with senior and critical care input.
If poor response: IV magnesium, then IV salbutamol or aminophylline with senior and critical care input.
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4
4. Admit or discharge
Admit for hypoxia, poor response, exhaustion, or social concern. Discharge when stable on inhalers 3 to 4 hourly with an action plan and technique checked.
Admit for hypoxia, poor response, exhaustion, or social concern. Discharge when stable on inhalers 3 to 4 hourly with an action plan and technique checked.
Severity (quick guide)
- Moderate: SpO2 92% or more, speaking, not distressed
- Severe: SpO2 under 92%, too breathless to talk or feed, HR and RR high
- Life-threatening: silent chest, poor effort, cyanosis, exhaustion, confusion
Pitfalls
- Under-dosing the initial bronchodilator
- Reassurance from a normalising CO2
- Delaying steroids
- Not checking inhaler technique before discharge
MedPrep - www.medprep.uk - Educational revision aid only. Not clinical guidance. Doses are adult examples; check the BNF, current guidelines and local policy, and seek senior advice. Nov 2026